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For many years, specialists have complained about the design of electronic health records, which, in their view, do not address the unique workflow and ancillary device requirements of their specialties. A new report from the IT committee of the American Academy of Ophthalmology describes exactly where EHRs fall short for eye doctors and how they could be improved.

Noting that the uptake of EHRs by ophthalmologists has been slower than that for physicians as a whole, the report points out that many eye doctors use comprehensive EHRs that were designed for primary care physicians and don't meet ophthalmologists' needs. For example, they may require doctors to enter vital signs, such as height and weight, that are different from the vital signs that eye specialists document, including visual acuity and intraocular pressure.

Some ophthalmologists use EHRs that have been built specifically for their field. But the companies that make these EHRs are usually small and may not have the resources to upgrade their software so that physicians can show Meaningful Use, the report points out.

Evan Steele, president and CEO of SRS Software, an EHR vendor based in Montvale, N.J., agrees with this analysis up to a point. The major vendors, he said, design their EHRs for practices of different sizes, not specialties. For example, Epic targets big groups, Greenway, midsized-groups, and eClinicalWorks, small practices, and Allscripts offers products for all three categories. Although the vendors claim to have versions for many different specialties, they're all primary care-oriented.

Most single-specialty EHR vendors are small, because they have a limited market, Steele said. As a result, they may have trouble keeping up with the later stages of Meaningful Use and the impending switchover to the ICD-10 diagnostic code set. SRS, he said, has the resources to keep up because it targets a broad range of specialties with high volume and high revenue per visit, including ophthalmology.

The report also points out that ophthalmology is visually intensive, requiring both anatomical drawings and notations on such drawings. The current mouse-based drawing methods just frustrate ophthalmologists because they're too hard to use and make it difficult to show sufficient detail.

Ophthalmologists also use a wide range of specialized imaging and measurement devices. The lack of interfaces between EHRs and many of these devices, and between EHRs and Picture Archiving and Communication Systems (PACS) are barriers to the rapid, accurate storage and retrieval of structured data.

Steele pointed out that it's very difficult for EHR vendors to interface with the myriad devices that are in use. Ophthalmology-specific vendors could write interfaces to these devices more easily, but that's a big burden on them financially. SRS provides a "lite" interface that allows imaging devices to export JPEG images to the EHR, which is superior to printing and scanning them, he said. Some eye groups also use ophthalmologic-specific PACS that easily interface with the SRS EHR, he added.

The report also points out that ophthalmologists work in a very high-volume environment in which patients are seen and evaluated at a rapid pace. That means physicians must be able to document care quickly and accurately. Ancillary staff, including midlevel practitioners and technicians, must be able to use the EHR easily.

In addition, since ophthalmology is both a medical and surgical specialty, "systems should associate electronically all relevant preoperative, operative, and postoperative documentation." In other words, EHR documentation should support the transitions between the office and the operating room.

In its recommendations for improving EHRs, the paper includes a list of 17 "essential" and six "desirable" features in the areas of clinical documentation, ophthalmic vital signs and laboratory studies, medical and surgical management, and ophthalmic measurement and imaging devices.

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